ED Coding & Reimbursement Alert - 2011 Issue 20
Modifiers: Modifier 57 Still Applies to Some Part B Claims, Despite Consult Pay Elimination
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Article Overview
This article reviews the continued role of modifier 57 in Medicare Part B billing after consult code reimbursement changes took effect. It is aimed at coders, billers, and physicians who work with evaluation and management services, surgical procedures, and global periods. The discussion focuses on how the modifier fits into Medicare claims, how it differs from other modifiers in broad terms, and why documentation and service timing matter.
Why This Topic Matters
Understanding this topic helps billing teams avoid claim denials and incorrect bundling when an evaluation and management service leads to surgery. It is especially relevant for practices that see Medicare patients and need to distinguish between consult-era habits and current payment rules.
Article Sections
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Background
Introduces the Medicare consult payment change and the general reason modifier 57 still comes up in Part B claims.
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Non-Consult E/M Codes Keep Modifier 57 Alive
Discusses the relationship between evaluation and management services and later surgical care, including the broad claim-processing context.
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Past
Reviews an earlier consult-based scenario and how it was handled before Medicare consult payment changes.
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Present
Describes the Medicare-oriented version of the scenario and the general role of the physician of record and initial hospital care coding.
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Consequence
Summarizes the claim impact that can occur when modifier 57 is not reported in the relevant circumstance.
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Differentiate Between Modifiers 25, 57
Compares the two modifiers at a high level and explains that their use depends on the timing and context of the service.
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What about pre-op visits?
Addresses preoperative visits and their relationship to the global package and modifier 57 in general terms.
What You Will Learn
- How modifier 57 is discussed in relation to Medicare Part B claims
- How consult code payment changes affected the relevance of modifier 57
- How evaluation and management services relate to later surgery in broad billing terms
- How modifier 57 is contrasted with modifier 25
- How global periods factor into the article’s discussion
- How preoperative visits are treated in the context of this guidance
Who Should Read This
- Medical coders
- Billing staff
- Physician practices
- Compliance teams
- Revenue cycle professionals
Codes Discussed
Code Ranges Discussed
Modifiers Discussed
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